Gastric Cancer Staging AJCC eighth edition - AGPSagps.org.au/resources/AGM_Stuff/2017_AGM/Update on...

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Gastric Cancer Staging AJCC eighth edition Duncan McLeod Westmead Hospital, NSW

Transcript of Gastric Cancer Staging AJCC eighth edition - AGPSagps.org.au/resources/AGM_Stuff/2017_AGM/Update on...

Page 1: Gastric Cancer Staging AJCC eighth edition - AGPSagps.org.au/resources/AGM_Stuff/2017_AGM/Update on Gastric AJCC 8th Ed.pdf · Gastric Cancer Staging AJCC eighth edition Duncan McLeod

Gastric Cancer Staging AJCC eighth edition

Duncan McLeod

Westmead Hospital, NSW

Page 2: Gastric Cancer Staging AJCC eighth edition - AGPSagps.org.au/resources/AGM_Stuff/2017_AGM/Update on Gastric AJCC 8th Ed.pdf · Gastric Cancer Staging AJCC eighth edition Duncan McLeod

Summary of changes

• New clinical stage prognostic groups, cTNM

• Postneoadjuvant therapy pathologic stage groupings, ypTNM - new prognostic information

• Change to anatomic boundary for staging carcinoma at oesophagogastric junction

• Changes to pathologic stage grouping

• Subclassification of N3

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• This staging does not apply to GIST or other sarcomas, lymphoma, or well differentiated neuroendocrine tumours

• Mixed adenoneuroendocrine carcinoma and poorly differentiated neuroendocrine carcinoma are staged by this system

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Tumours to stage by gastric carcinoma system

• A tumour with epicentre more than 2cm from the oesophagogastric junction or;

• A tumour centred within 2cm of the oesophagogastric junction but not crossing it

• Therefore if centred within proximal 2cm of stomach and crossing OGJ, stage by the oesophageal staging system

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Clinical staging

• Application of pathologic stage groupings to clinical staging has not been validated and may not be appropriate

• New prognostic stage groupings

– Separate data set of surgically treated and non-surgically treated patients (USA & Japan, 4091 pts)

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Clinical staging investigations

• Endoscopic ultrasound (EUS)

• CT

• Laparoscopy +/- biopsy and washings cytology

• MRI

• PET-CT

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EUS

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Clinical staging

• Lymph nodes – round, circumscribed echogenic structures >10mm on EUS considered positive node

• FNA confirmation of mets via EUS encouraged

• EUS may see some liver mets

• On CT lymph nodes which are round &/or >10mm in short axis diameter are suspicious

• PET/CT limited due to false negative rate

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Diagnostic laparoscopy

• For cT3 or greater

• If clinically suspicious nodes without distant mets on imaging

• Visible peritoneal mets – biopsy

• Washings should be done

• Positive washing cytology = pM1, incorporated into clinical stage; cTcNpM1

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Clinical Prognostic Stage Groups (cTNM)

• Different to pathologic stage groups • Simplified nodes – involved or not • cT4b NX M0 has poor prognosis,

hence is stage IV

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Pathologic Staging

• Based on more than 25000 gastric adenocarcinoma patients, Asian and western, treated by surgery, min. 5yrs follow up

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Changes to TNM definitions

• pN3 ->

– pN3a metastases in 7 to 15 regional lymph nodes

– pN3b metastases in 16 or more regional lymph nodes

• However this was the case in the 7th edition

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Definitions – primary tumour

• TX Primary tumour cannot be assessed • T0 No evidence of primary tumour • Tis Carcinoma in situ • T1a Tumour invades lamina propria or muscularis mucosae • T1b Tumour invades submucosa • T2 Tumour invades muscularis propria • T3 Tumour penetrates subserosal tissue without invasion

of visceral peritoneum or adjacent structures • T4a Tumour penetrates serosa (visceral peritoneum) • T4b Tumour directly invades adjacent organs or structures

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Pathologic staging – primary tumour

• Invasion of greater or lesser omentum, gastrocolic or gastrohepatic ligaments without breach of peritoneum is T3

• Breach of peritoneum = T4

• Intramural extension along alimentary canal into oesophagus or duodenum is not invasion of adjacent organ (ie. Not T4b)

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Definitions – Lymph nodes

• NX Regional lymph nodes(s) cannot be assessed

• N0 No regional lymph node metastases

• N1 Metastases in 1-2 regional lymph nodes

• N2 Metastases in 3-6 regional lymph nodes

• N3a Metastases in 7-15 regional lymph nodes

• N3b Metastasis in 16 or more regional lymph nodes

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Pathologic staging - Lymph nodes

• At least 16 nodes, 30 or more desirable

• Metastatic carcinoma deposits in subserosal fat with no residual node and no vascular or neural structure are regarded as lymph node deposits

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Regional lymph node groups

• Perigastric along greater curvature • Perigastric along lesser curvature • Right and left paracardial (cardio-oesophageal) • Suprapyloric • Infrapyloric • Left gastric artery • Celiac artery • Common hepatic artery • Hepatoduodenal (along proper hepatic artery, including

portal) • Splenic artery • Splenic hilum

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Diagram of lymph node groups

Perigastric lymph nodes

Second tier nodes

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Non-regional (distant) lymph nodes

• Retropancreatic, pancreaticoduodenal, peripancreatic, superior mesenteric, middle colic, para-aortic, retroperitoneal, others

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Japanese Gastric Cancer Association 2011

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Definitions – Distant metastases

• M0 No distant metastasis

• M1 Distant metastasis

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Distant metastases

• Liver

• Peritoneum

• Non-regional lymph nodes

• Lung, CNS – less common

• Direct extension into liver, colon, pancreas, diaphragm = T4b, not M1

• Positive peritoneal cytology = M1

• May incorporate clinical M stage into pathologic

Page 26: Gastric Cancer Staging AJCC eighth edition - AGPSagps.org.au/resources/AGM_Stuff/2017_AGM/Update on Gastric AJCC 8th Ed.pdf · Gastric Cancer Staging AJCC eighth edition Duncan McLeod

Changes to pathologic stage groups

• pT4aN2 and pT4bN0 are now Stage IIIA (previously IIIB)

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Pathologic Prognostic Stage Groups (pTNM)

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Survival by pathologic stage groups

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Survival by clinical stage (cTNM)

USA (surgery and no surgery) Japan (surgically treated)

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Post-neoadjuvant therapy stage groupings

• New prognostic groupings for ypTNM

• Separate data set, approx. 700 patients

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Post-Neoadjuvant therapy classification

• Acellular mucin is not regarded as residual tumour

• ypT based on deepest level of residual carcinoma cells

• Positive lymph nodes must have some residual carcinoma cells

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Tumour regression

• Combined gross and microscopic assessment

• Tumour regression may be expressed as percentage loss of tumour cells in the tumour bed (area of fibrosis +/- inflammation), ie. 100% treatment response = fibrosis with no carcinoma

• Residual carcinoma cells = incomplete response

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Post neoadjuvant Therapy Prognostic Stage Groups

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Survival of patients treated by neoadjuvant chemoradiation and

surgery by yp stage groups

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Other recommended prognostic factors

• Serum CEA and CA19-9 levels for monitoring in surveillance period after baseline levels

• HER2 for consideration of HER2 therapy

• MSI – better prognosis for MSI-H but prognostic value not established

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Carcinoma grade

• GX Grade cannot be assessed

• G1 Well differentiated

• G2 Moderately differentiated

• G3 Poorly differentiated

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Carcinoma classification

• According to WHO classification 2010

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Gastric Neuroendocrine Tumours - changes

• Prognostic stage groups have been condensed; no more substages

• Additional factor for clinical care is recommendation for measurement of serum gastrin levels – aid in classifying the neuroendocrine tumour (type 1 and 2 with elevated gastrin levels, type 3 normal)

• Pancreatostatin an emerging prognostic factor for clinical care

Page 39: Gastric Cancer Staging AJCC eighth edition - AGPSagps.org.au/resources/AGM_Stuff/2017_AGM/Update on Gastric AJCC 8th Ed.pdf · Gastric Cancer Staging AJCC eighth edition Duncan McLeod

Definitions of primary tumour (T)

• TX Primary tumour cannot be assessed

• T0 No evidence of primary tumour

• T1 Tumour invades lamina propria or submucosa and less than or equal to 1cm in size

• T2 Tumour invades muscularis propria or greater than 1cm in size

• T3 Tumour invades into subserosal tissue without penetration of visceral peritoneum

• T4 Tumour penetrates serosa (visceral peritoneum) or invades adjacent organs or structures

Page 40: Gastric Cancer Staging AJCC eighth edition - AGPSagps.org.au/resources/AGM_Stuff/2017_AGM/Update on Gastric AJCC 8th Ed.pdf · Gastric Cancer Staging AJCC eighth edition Duncan McLeod

Definitions of regional lymph nodes

• NX Regional lymph nodes cannot be assessed

• N0 No regional lymph node metastasis

• N1 Regional lymph node metastasis

Page 41: Gastric Cancer Staging AJCC eighth edition - AGPSagps.org.au/resources/AGM_Stuff/2017_AGM/Update on Gastric AJCC 8th Ed.pdf · Gastric Cancer Staging AJCC eighth edition Duncan McLeod

Definition of distant metastases

• M0 No distant metastases

• M1a Metastasis confined to the liver

• M1b Metastasis to at least 1 extrahepatic site (eg. Lung, ovary, non-regional lymph node, peritoneum, bone)

• M1c Both hepatic and extrahepatic metastases

Page 42: Gastric Cancer Staging AJCC eighth edition - AGPSagps.org.au/resources/AGM_Stuff/2017_AGM/Update on Gastric AJCC 8th Ed.pdf · Gastric Cancer Staging AJCC eighth edition Duncan McLeod

Gastric neuroendocrine tumour pathologic stage groups

Some options are left out: T0 TX and NX combined with M1 = stage IV Online errata spreadsheet